The past few months have been, as we all know, full of consequence for health. Recently, this has coalesced around challenges in this country which reflect our history of racial injustice and its present-day effect on the health of populations. With this in mind, I would like to share some thoughts about this moment, drawn from past reflections, and informed by current events.
A brief story, to begin. A colleague recently mentioned being on a Zoom call where the host asked if the participants had lost loved ones to COVID-19. Most said something like “No, thank goodness,” or perhaps they did know one or two people who died. Then, the one African American woman on the call spoke. She had lost 14 people in her circles to COVID-19.
I start with this story because I realize that sometimes our population health data mask the human tragedy. This story is sadly in line with what we are learning about who COVID-19 most affects. It is most deadly to people with preexisting conditions. And in America, to our shame, we have allowed being black to be a preexisting condition when it comes to health. From life expectancy to maternal mortality, black populations suffer a disproportionate burden of poor health. And blacks are significantly likelier to die from COVID-19.
It is especially tragic that we are seeing these health gaps so clearly reflected by the pandemic when we are also seeing how the lived experience of racism threatens public health. The Central Park birder incident, and, more saliently, the deaths of Ahmaud Arbery and George Floyd reflect the continued presence of racism in our society, and the physical and mental toll it takes on communities of color.
Racism, health gaps, violence—these are unique manifestations of harm visited on black and brown populations. Yet they emerge from the same fundamental injustice, informed by the legacy of slavery, which has for so long prevented our society from being as healthy as it can be. This reflects what is, to my thinking, a core truth about health: there can be no health without social justice.
Reflecting on the importance of social justice, it is always helpful to return to the words and example of Dr. Martin Luther King Jr. While he was confined to a Birmingham jail in 1963, Dr. King wrote, “I am in Birmingham because injustice is here…I am cognizant of the interrelatedness of all communities and states. I cannot sit idly by in Atlanta and not be concerned about what happens in Birmingham. Injustice anywhere is a threat to justice everywhere.” King’s eloquence is both inspiring and direct in its implications for public health. It speaks to the urgency that informs our work, and the work of anyone who tries to help populations that are under threat. It is worth noting that King took care to ground his sense of justice in an awareness of the “interrelatedness of all communities.” He recognized, as we must, that inequities are never the exclusive problem of the group they seem to most directly affect. Health, in particular, is interconnected; whenever a distinct group suffers from poor outcomes, the burden will be shared across populations in ways both subtle and overt.
Our pursuit of public health is therefore inextricably intertwined with how effectively we can pursue social justice to reduce inequities within populations, for the good of all populations. This is perhaps best captured by the observation that the US spends far more on health care than any other country in the world, but has far worse health outcomes than any of our peer countries. The reason is simple: we devote extraordinary resources to delivering perhaps the best medical care in the world, but shamefully few resources towards correcting the underlying social, economic, and cultural structures that shape health inequities within our population. This is well captured every time we note, for example, the higher risk of heart trouble run by Latinos, or the fact that black people die sooner than white people.
I realize that, in discussing social justice in these terms, I am saying out loud what many might consider to be implicit in our work, and so this note could perhaps be characterized as a statement of the obvious. I persist for three reasons.
First, as scholars we know that there is often utility in reestablishing first principles. Indeed, social justice is so central to public health that it becomes, paradoxically, easy to overlook, like water to the proverbial fish.
My second reason has to do with how we communicate our message. While the social justice component of public health might be clear to us, it is not necessarily clear to the wider world. Where we see disparities, for example, many may only see a need for better treatment, or perhaps take the view that lopsided health outcomes are merely an unfortunate fact of life. Historically, this view has obstructed many justice-oriented change movements. At the time of Dr. King’s incarceration, the problem of Jim Crow, while obvious to us now as a moral travesty, was to some just another aspect of the American status quo. Many people did not see it this way, of course, and it is in large part thanks to the success of these dissenters at framing the issue as a matter of social justice that we no longer have legalized segregation in this country. Our own efforts would benefit from a similar, concerted emphasis.
Third, the statement and restatement of core challenges stands to nudge, to make a difference. Writing with unprecedented fierceness in The Jungle, Upton Sinclair denounced mistreatment of employees, and the inhumane conditions under which they worked in the meatpacking industry in Chicago about 100 years ago. His work was a quintessential call to social justice, leading to legislation that regulated a range of economic activity. It was a notable example of the resonance of social justice as a call to action, with direct implications for the improvement of the health of the public.
Over the years, there has been progress in narrowing health gaps between communities of color and the rest of the population. But we are far from being able to call this a problem which has been solved.
My heart goes out to the victims of such injustice. But sorrow means little if it does not inform action. What should action entail, in this case? It should mean creating a society where structural racism no longer threatens health.
This calls on us to address the full range of socioeconomic challenges, which, informed by racial attitudes, have long undermined health. But, more than that, it means acknowledging the historic injustice which is the soil in which these poisoned trees took root—the legacy of slavery.
COVID-19 has upended life in this country, and has been tragic for many, especially communities of color. But it is also true—though perhaps a hard truth—that much in the US needed upending; our racial status quo most of all. Rebuilding after COVID-19 should not mean merely reconstructing the past. We need to lay the foundation for a better future, the structures of racism replaced by those which support health, those of justice. To do otherwise would be to do a disservice to those who have died, to their loved ones, and to all those the American past has marginalized and excluded.
We can do better. If we do not do so now, when will we?
Please join us on June 3, at 5:00 pm, for a Conversation on Race and Policing, led by students, staff, and faculty, an opportunity for us to have a conversation as a community about these issues.
Sandro Galea, MD, DrPH
Dean and Robert A. Knox Professor
Boston University School of Public Health
Previous Dean’s Notes are archived at: http://www.bu.edu/sph/tag/deans-note/